"In the past" - said Robert Cooper, one of Europe's pre-eminent diplomats - "it was enough for a nation to look after itself. Today it is no longer sufficient."1 This is particularly true in the health arena. There is an increasing range of health issues that transcend national boundaries and require action on the global forces that determine the health of people. The broad political, social and economic implications of health issues have brought more diplomats into the health arena and more public health experts into the world of diplomacy. Simple classifications of policy and politics - domestic and foreign, hard and soft, or high and low - no longer apply.2

Diplomacy is frequently referred to as the art and practice of conducting negotiations.3 It is usually still understood to mean the conduct of international relations through the intervention of professional diplomats from ministries of foreign affairs with regard to issues of "hard power", initially war and peace, and - as countries compete economically - economics and trade. But in recent years there has also been an increase in the number of international agreements on "soft issues", such as the environment and health; it is now recognized that some of these issues have significant "hard" ramifications on national economies. The term "global health diplomacy" aims to capture these multi-level and multi-actor negotiation processes that shape and manage the global policy environment for health.

Global health diplomacy is at the coal-face of global health governance - it is where the compromises are found and the agreements are reached, in multilateral venues, new alliances and in bilateral agreements. It is a world to which outsiders find it difficult to relate, where the art of diplomacy juggles with the science of public health and concrete national interest balances with the abstract collective concern of the larger international community in the face of intensive lobbying and advocacy. No longer do diplomats just talk to other diplomats - they need to interact with the private sector, nongovernmental organizations, scientists, activists and the media, to name but a few, since all these actors are part and parcel of the negotiating process.

Global health diplomacy is gaining in importance and its negotiators should be well prepared. Some countries have added a full-time health attaché to their diplomatic staff in recognition of the importance and complexity of global health deliberations; others have added diplomats to the staff of international health departments. Their common challenge is to navigate a complex system in which issues in domestic and foreign policy intertwine the lines of power and constantly influence change, and where increasingly rapid decisions and skilful negotiations are required in the face of outbreaks of disease, security threats or other issues. Missions to the United Nations and international organizations - for example, in New York and Geneva - increasingly need to deal with health issues, as do the classical bilateral embassies.

An important part of global health diplomacy still takes place within the World Health Organization; indeed it has recently gained new momentum through the negotiation during the past five years of the Framework Convention on Tobacco Control and the International Health Regulations. But the venue of global health diplomacy has shifted to include other spaces of negotiation and influence, and the number of organizations dealing with health has increased exponentially. At all levels we are witnessing a diversification of actors, the most illustrative development being the growth of public-private partnerships and platforms around a multitude of health issues, all clamouring for attention and funds. It is clear that the profound change underway requires new mechanisms and new skills for global health diplomacy. Yet an informal survey by the authors of staff of the international departments of health in countries that belong to the Organisation for Economic Co-operation and Development (OECD), in Latin America and of health attachés in Geneva has confirmed that many do not feel well prepared for the challenges that confront them.

Strengthening health diplomacy

Anne Marie Slaughter states in her influential book on global policy networks:

"Understanding 'domestic' issues in a regional or global context must become part of doing a good job. Increasingly, the optimal solution to these issues will depend on what is happening abroad, and the solutions to foreign issues, in corresponding measure, by what is happening at home."4

In the following section we give a short description of health diplomacy initiatives in two countries, Switzerland and Brazil, in which the authors have been involved, and which underline and illustrate Slaughter's point.

Switzerland: ensuring policy coherence

As globalization processes expand it becomes essential for countries to manage a two-way process: as the interdependence of countries grows, all national health policies have a significant global dimension, and as the number of international agreements grows, the impact of such agreements on national policy-making will also increase. The recognition of the need for policy coherence, strategic direction and a common value base in global health is only just beginning to emerge at the level of nation states. A few European countries are beginning to address global health more consistently at the national level by mapping many activities in global health across all government sectors, establishing new mechanisms of coordination within government and developing a "national global health strategy", frequently at the initiative of the international departments in the ministries of health. The most recent - and possibly the first - such policy document has been developed in Switzerland, where a joint strategic approach to global health was developed by the Departments of the Interior (represented by the Swiss Federal Office of Public Health) and the Department of Foreign Affairs. This document, Agreement on foreign health policy objectives, was presented to the Swiss Federal Council (the government cabinet) in October 2006.5 It is the first of a number of special strategic agreements that the Department of Foreign Affairs is developing with different policy sectors within government; this in itself is a significant signal of the change in diplomacy that is underway.

The document brings together three major strands of global health action that generally run in parallel with little coordination or even in competition. These are: the activities within the health sector that address normative health issues, international agreements and cooperation, global outbreaks of disease and pandemics; the commitment to health in the context of assistance towards development; and the policy initiatives in other sectors - such as foreign policy and trade. It underlines the commitment of Switzerland to human rights and defines five priorities in foreign health policy: the health of the Swiss population, the coherence between national and international health policy, the strengthening of international health cooperation, the improvement of the global health situation, and the strengthening of the Swiss commitment as host country to WHO and to major health industries.

Brazil's health policy goals

Coalitions of developing countries as well as leadership from some of the middle-income countries such as Brazil have contributed to a significant power shift within global health diplomacy. The determining factor in Brazilian health diplomacy is the fact that in Brazil health is a right of the people and an obligation of the Brazilian state - as set down in the Brazilian constitution. Had Brazil completed free trade agreements with the United States - such as the Free Trade Agreement or the Free Trade Agreement of the Americas - it would not have been possible to assure delivery of the health services and drugs that are currently available to the population. Brazil's actions at the 2001 World Trade Organization conference in Doha, Qatar, and its position concerning the Agreement on Trade Related Aspects of Intellectual Property Rights declaration - which recognized health as a priority over international trade - are cases in point. Brazilian global health diplomacy now starts from the premise that it is the health of the population that needs to be the centre of attention of diplomacy.

One of the best examples of the close cooperation between the Ministry of Foreign Affairs and the Ministry of Health in Brazil is global policy on human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), in particular, the access to antiretroviral drugs. The presence of health experts was crucial, since a diplomat when discussing his own field of expertise, such as intellectual property, does not necessarily know about specific aspects of the production of drugs in the country or the policies regarding drug prices. The Ministry of External Relations has pointed out that the "visibility of the Ministry of Health, both in the technical and political levels, was crucial for the credibility of this position. Our leadership was, therefore, doubtlessly, a result of this credibility."

The participation of the Brazilian diplomats in the fight against tobacco reinforced the country's leading role in international health forums, and has further strengthened the bonds between health and diplomacy. When assuming the presidency of the Intergovernmental Negotiating Body, Ambassador Celso Amorim from Brazil reaffirmed not only the need to bring health into foreign policy, but also to bring foreign policy into health. Brazilian global health diplomacy was grounded on the country's solid preparation "back home" with the National Commission for Tobacco Control, headed by the Ministry of Health and gathering representatives from different ministries (health, agriculture, international relations, treasury, education, environment, trade and industry, and communications). Again this illustrates the point that good global health governance begins at the national level: this intensive multi-sector preparation allowed the Brazilian delegation to intervene in almost all working groups of the negotiation process. The final document, therefore, had major contributions from the Brazilian delegation, which underlined the crucial link between the national and the global and further manifested itself in the success of the Tobacco and Other Cancer Risk Factors National Control Program in Brazil.

Action in capacity building

These examples underline the need to build capacity for global health diplomacy by training public health professionals and diplomats respectively. Two types of imbalance need to be addressed as a priority: imbalances that can emerge between foreign policy and public health experts, and imbalances that exist in the negotiating power and capacity between developed and developing countries.

Both Brazil and Switzerland have taken initiatives to address these imbalances through networking, experience-exchange and capacity building. Switzerland has initiated an experience-exchange between heads of department of international health from OECD countries to track their changing role in global health diplomacy. Brazil has made its experiences available through cooperation with most Latin American countries and with the Portuguese-speaking African countries. The Ministry of Health has also embarked on a dialogue with the Brazilian School of Diplomacy to explore a two-way capacity building exercise together with the National School of Public Health and the Oswaldo Cruz Foundation. The Swiss Federal Office for Public Health is supporting an initiative to introduce global health into graduate studies in foreign relations at the Graduate Institute of International Studies in Geneva. A new programme, "Global health diplomacy", will seek to explore the unique interface between the theory and the practice of international relations in the field of health and use the unique location of Geneva as the global health capital to introduce the global public health community to the challenges faced in global diplomacy.

Diplomacy - to paraphrase Robert Cooper once more1 - needs a post-modern perspective. "The objective of foreign policy", he writes, "is taken to be peace and prosperity rather than power and prestige." Diplomacy opened in the 1950s to economy and trade, enlarged in the 1980s to the environment and starts the 21st century with health as its focus.

Competing interests: None declared.

References

1. Cooper R. The breaking of nations. Order and chaos in the 21st century. New York: Atlantic Monthly Press; 2003

4. Slaughter AM. A new world order. Princeton and Oxford: Princeton University Press; 2004.

5. Agreement on foreign health policy objectives. Adopted by the Swiss Federal Department of Foreign Affairs and the Swiss Federal Department of Home Affairs in Berne, Switzerland, on 9 October 2006. Available from: www.bag.admin.ch/international